diabetes 2020 session 2 handout...prior to diagnosis of type 2 diabetes 1.00 2.40 3.19 3.64 0.00...
TRANSCRIPT
Page 1© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
Diabetes 2020 – Session 2 Cardiovascular Risk Reduction
Beverly Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
Welcome Everyone
•Recorded version ready later on same day
• Questions? [email protected]
or phone 530/893-8635
Reading Material
DiabetesEdUniversity.net
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Bev has no conflict of interest� She’s not on any speakers
bureau
� Does not invest
� Gathers information from reading package inserts, research and standards
� She does engage in “pill-ow” talk with her husband (who is a PharmD)
Session 2 Topics
�Session 2 – Cardiovascular
Risk Reduction Strategies
�ADA and AACE Guidelines
for CV Risk Reduction
�Implement Risk Reduction
Strategies
�Addressing Hypertension,
Lipids
Let’s elevate our role
Cardiometabolic risk reduction
Diabetes technology resource
Provide meaningful person-centered care and support the emotional well-being of the whole person.
Ensure that everyone knows what your role is as a core member of the larger care team
Offer care that positively impacts quality and cost and enhances the experience for both the person with diabetes and provider.
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10. Cardiovascular Disease and Risk
Management
�Heart disease is the leading cause of mortality and morbidity in diabetes
�Large benefits are seen when multiple risk factors are addressed globally
Insulin Resistance is the Seed
�Muscles are insulin
resistant
� Building muscle decreases
insulin resistance
�Fat cells become more
insulin resistant
� Leads to more Free Fatty
Acids and Triglycerides
� More vascular inflammation
�Pancreas becomes fatty
� Losing wt helps improve
Insulin Resistance
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BMI – Visual Image
Poll question 1
�Which of the following BEST
describes insulin resistance? a. Lack of sufficient insulin receptors on
fat and muscle cells.
b. Visceral adipose tissue.
c. A physiological condition where
insulin becomes less effective at
lowering blood glucose levels.
d. Excessive triglyceride levels
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American College of Endocrinology, 2001
Factors Associated with Insulin
Resistance
�Abdominal obesity
�Sedentary lifestyle
�Genetics / Ethnicity
�Gestational Diabetes
�Polycystic ovary syndrome
�Acanthosis Nigricans
�Obstructive Sleep Apnea
�Cancer
Acanthosis Nigricans
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Acanthosis Nigricans (AN)
�Signals high insulin levels in bloodstream
and is a marker of insulin resistance
�Patches of darkened skin over parts of body
that bend or rub against each other
� Neck, underarm, waistline, groin, knuckles, elbows,
toes
� Skin tags on neck and darkened areas around eyes,
nose and cheeks.
�No cure, lesions regress with treatment of
insulin resistance
Risk of CVD Is Elevated
prior to Diagnosis of Type 2 Diabetes
1.00
2.40
3.19
3.64
0.00
1.00
2.00
3.00
4.00
5.00
Non-diabetic
throughout
study
15 yrs or more
before
diagnosis
10-14.9 yrs
before
diagnosis
<10 years
before
diagnosis
Re
lati
ve
Ris
k o
f M
I* o
r S
tro
ke
*MI = myocardial infarction. Nurses Health Study
Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.
Natural History of Diabetes
Normal
FBG <100
Random <140
A1c <5.7%
Prediabetes
FBG 100-125
Random 140 - 199
A1c ~ 5.7- 6.4%
50% working pancreas
Diabetes
FBG 126 +
Random 200 +
A1c 6.5% or +
20% working pancreas
Development of type 2 diabetes happens over years or decades
Yes! NO
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3. PreDiabetes is FREAKING ME OUT
�86 million people in US�90% don’t know they have
it�In 3-5 years, about 30% of
predm will get diabetes�Associated with higher
rates of heart attack, stroke, neuropathy and vessel disease
�Why isn’t is called stage 1 diabetes?
3. Prevention or Delay of Type 2
�Prediabetes is associated with
heightened cardiovascular risk;
therefore, screening for and
treatment of modifiable risk factors
for cardiovascular disease are
suggested.
Standards of Medical Care in Diabetes - 2020. Diabetes Care 2020;43(Suppl. 1)
What is Type 2 Diabetes?
�Complex metabolic disorder ….
(Insulin resistance and deficiency)
with social, behavioral and
environmental risk factors unmasking
the effects of genetic susceptibility.
New Diagnosis? Call 800 – DIABETES to request “Getting Started Kit”www.Diabetes.org
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Cardio Metabolic Risk -
5 Hypers -
�Hyperinsulinemia (resistance)
�Hyperglycemia
�Hyperlipidemia
�Hypertension
�Hyper”waistline”emia (35” women, 40” men)
Manifestations of Insulin Resistance
Poll question 2
�Which of the following Cardiovascular
Conditions are associated with
diabetes?
A. Congestive Heart Failure
B. Hypervasodilation
C. Acanthosis Nigricans
D. CardioNephritis
Heart Disease & DM = 3-5xs Risk
�CHF � 7.9 % w/ diabetes vs. � 1.1 % no diabetes
�Heart attack � 9.8 % w/ diabetes vs.� 1.8 % no diabetes
�Coronary heart disease � 9.1 % w/ diabetes vs. � 2.1 % no diabetes
�Stroke � 6.6 % w/ diabetes vs. � 1.8 % no diabetes
� 2007 AACE
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Page 9© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
Cardiovascular Disease and Risk Management
�Cardiovascular disease is the leading cause of mortality and morbidity in diabetes
�Largest contributor to direct and indirect costs
�Controlling cardiovascular risk improves outcomes
�Large benefits are seen when multiple risk factors are addressed globally
Poll question 3
�What is the relationship between
diabetes and cardiovascular disease?
A. Diabetes is associated with a lower rate of
congestive heart failure.
B. Diabetes is associated with decreased
incidence of heart attack and stroke
C. People with diabetes are destined to get CV
complications.
D. People with diabetes can decrease their risk of
a CV event
Diabetes & Heart Disease Motivational
Stats
� Every 18 mg/dl increase in
fasting glucose increases risk
of CV events/death by 17%
� Every 1% increase in A1c
increased:
� CVD events by 18%
� MI events by 19%
� All cause mortality by 12-14%
� Microvascular disease by 35%
ADA Standards of Care
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ABCs of Diabetes
�A1c less than 7% (avg 3 month BG)�Pre-meal BG 80-130
�Post meal BG <180
�Blood Pressure < 140/90
�BP target <130/80
�If 10 year CVD Risk > 15%
�Cholesterol � Statin therapy indicated?
Vascular Risk Factors
�Modifiable� Glucose
� Blood Pressure
� Lipids
� Smoking
� Weight
� Dietary Habits
� Other factors – lack of exercise,
Type A personality
Poll Question 4
�Which of the following is the
best recommendation to
protect cardiovascular
health?
A. Avoid all fast foods
B. Stop smoking
C. Keep B/P as low as possible
D. Eliminate sugar from diet
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•Ask at every visit
•Assess
•Advise
•Assist with stop smoking
•Arrange for referrals
•Organize your clinic
Smoking and Diabetes
Smoking increases risk of diabetes 30%
Smoking and Diabetes
DASH Diet – Dietary Approaches to Stop
Hypertension
�The DASH diet emphasizes vegetables,
fruits and low-fat dairy foods — and
moderate amounts of whole grains, fish,
poultry, nuts.
�Pt recommendations
� Eat lots of whole grains, fruits, vegetables and
low-fat dairy products.
� Also includes some fish, poultry and legumes,
and encourages a small amount of nuts and
seeds a few times a week.
� Red meat, sweets and fats in small amounts.
� Focus on low saturated fat, cholesterol, total fat.
Mediterranean Diet Pyramid
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Benefits of Exercise and Diabetes
�Increase muscle glucose uptake 5-fold
�Glucose uptake remains elevated for 24 - 48 hours (depending on exercise duration)
�Increases insulin sensitivity in muscle, fat, liver.
�Reduce CV Risk factors (BP, cholesterol, A1c)
�Maintain wt loss
�Contribute to well being
�Muscle strength
�Better physical mobility
Using Alcohol Safely
�Women 1 or fewer alcoholic drinks a day
�Men 2 or fewer alcoholic drinks a day� 1 alcoholic drink equals
� 12 oz beer, 5 oz glass of wine, or 1.5 oz distilled spirits (vodka, gin etc)
�If drink, limit amount and drink w/ food.
�Can cause hypo, worsen neuropathy and increase triglycerides
Periodontal disease and Heart Disease
Heart disease link:
oral bacteria enter the blood
stream, attach to fatty plaques in
coronary arteries increasing clot
formation
inflammation increases plaque
build up, which may contribute
to arterial inflammation
Hyperglycemia = Gingivitis =
Heart Disease
PreventiveAction• Brush twice daily• Floss daily• See dental team a
few times a year
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Page 13© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
“Legacy Effect”�For participants of DCCT and UKPDS � long lasting benefit of early intensive BG
control prevents�Macrovascular complications 42% reduction in CV disease
57% reduction in nonfatal MI, Stroke or CVD death
�Microvascular complications
�Even though their BG levels increased over time
�Message – Catch early and
Treat aggressively
Section 9- Pharmacologic Approaches to
Glycemic Treatment
�Algorithm for Oral Meds
and Insulin Therapy
�More attention to
considering CVD and CKD
when choosing diabetes
medication
�Updated chart on cost and
attributes of different meds
Medication Taking Behaviors
� Adequate medication taking is
defined as 80%
� If pt taking meds 80% of time and
treatment goals not met,
intensification should be considered.
� Barriers to taking meds include:
� Forgetting to fill Rx, fear, depression, health
beliefs, medication complexity, cost, system
factors, etc.
� Work on targeted approach for
specific barrier
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Page 14© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
A 78 yr old man, smokes ppd
�A1c was 8.1%, History of MI
�B/P 136/76 AM BG 100, 2 hr pp 190
�Chol – TG 54, HDL 46, LDL 98
�Meds:� Insulin – 16 units Lantus at HS
�Benazepril 20 mg
�Metoprolol 50mg
�Warfarin 5mg
�Actos 15 mg
What class of meds is this patient on?Any diabetes meds missing?
ADA Step Wise Approach to
Hyperglycemia 2020
�For all steps, consider including
medications with evidence of ASCVD
and CKD risk reduction, based on drug
specific effects and patient factors.
�Other Factors�Minimize Hypoglycemia
�Minimize wt gain or promote wt loss
�Consider Cost
Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac
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SGLT2 Inhibitors- “Glucoretics”
� Action: “Glucoretic” decreases renal reabsorption in the proximal tubule of the kidneys (reset renal threshold and increase glucosuria). Risk of ketoacidosis, Fournier's gangrene
% ‘f
Decreases GlucoseReabsorption
ADA Step Wise Approach to
Hyperglycemia 2020� Step 1 – Metformin + Lifestyle
� Step 2 - If A1c target not achieved after 3 months, Metformin + another med
� If ASCVD, CHF, or CKD, consider adding a second agent to reduce risk based on drug effects and individual factors.
� SGLT-2i - Empagliflozin (Jardiance), canagliflozin (Invokana) and dapagliflozin (Farxiga) – Eval GFR
� GLP-1 RA Semaglutide > liraglutide > dulaglitide > exenatide > lixisenatide
� Step 3 - If A1c target still not achieved after 3 months, combine metformin plus one to two other (2-3 drugs)
� Step 4 - If A1c target not achieved after 3 months, add injectable therapy (GLP-1 RA or Basal insulin) to drug combination.
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Page 16© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
ADA Standards 2020
Atherosclerotic CV Disease
�ASCVD risk – how is that defined?
�55+ with previous event, coronary, carotid,
lower extremity artery stenosis > 50% or
Left Ventricular Hypertrophy (LVH)
�Preferred Meds:
�SGLT-2s that reduce heart failure, CKD
progression, Cardiovascular Outcomes Trial
(CVOT)
�Empagliflozin (Jardiance), canagliflozin
(Invokana) and dapagliflozin (Farxiga) ADA Stds – InjectablesAlgorithm small print
Heart Failure (HF) or Chronic Kidney
Disease Predominate� If HF or reduced Ejection Fraction (rEF) and Left
Ventricular Ejection Fraction (LVEF) <45%
� Kidney disease� CKD: If eGFR 30-60 or
� Urine Albumin to Creatinine Ratio (UACR) > 30 mg/g especially if UACR > 300
� Use SGLT2i if eGFR is adequate
� Empagliflozin (Jardiance), canagliflozin (Invokana),
dapagliflozin (Farxiga)
� If can’t tolerate, use GLP-1 RA � Semaglutide > liraglutide > dulaglitide > exenatide >
lixisenatide
� Insulin Basal next - Risk of hypo; least to most
� Degludec /glargine U300 < glargine U100 < detemir < NPH
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Page 17© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2019
Principles of AACE Type 2 Management
Algorithm
�Lifestyle modification
�Avoid hypo, wt gain
�Individualize targets
�Therapy choices are person centered and include ease of use, affordability
�Therapy choice considers cardiac, CHF, renal status
�Get to goal ASAP
�Manage co-conditions
� CGM is highly recommended
�Optimal A1c <6.5%AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2020
Poll Question 5
�George type 2, is losing weight and thirsty with an A1c of 10.3%. Using AACE guidelines, what is appropriate action?
a. Evaluate lifestyle changes for 3 months
b. Start insulin therapyc. Start metformin immediatelyd. Start metformin plus another
agent
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Page 18© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
Clinical Inertia Happens
�Reassess every 3-
6 months
Assess ASCVD and Heart Failure Risk Yearly
� Obesity/overweight
� Hypertension
� Dyslipidemia
� Smoking
� Family history of premature coronary disease
� Chronic kidney disease
� Presence of albuminuria
� Hypoglycemia Risk
� Therapeutic Treatment Plan and Goal Setting
� Lifestyle, meds, monitoring, referral to DSME
ASCVD (Atherosclerotic Cardiovascular Disease)
Assessment
�ASCVD Risk Calculator
�http://tools.acc.org/ASCVD-Risk-Estimator-Plus
�Evaluate 10 year risk of CV events (age 40-59)
�
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Poll question 6
�What is the current B/P goal for
people with diabetes.�A. 130/80
�B. 140/80
�C. 120/70
�D. 140/90
BP and Diabetes Targets� Calculate ASCVD Risk using calculator:
� BP target <140/90
� If CVD Risk <15%
� BP target <130/80
� If 10 year CVD Risk > 15%
�BP target based on individual assessment and
shared decision making that addresses CV
Risk and potential adverse effects of BP meds.
�During pregnancy, with previous history of HTN� B/P Target is ≤135/85
BP GoalBP Goal based on risk� Measure B/P at every
routine clinical visit.
� If B/P elevated, confirm B/P using multiple readings, including measurements on a separate day, to diagnose HTN
� All with diabetes and HTN should monitor BP at home.
� Some may benefit from B/P 130/80 (younger and achieved with undue txburden)
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Page 20© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
HTN Lifestyle Treatment Strategies
�If BP > 120/80, start with lifestyle
�Lose weight through less calories
�Sodium intake <2,300mg/day
�Eat more fruits & veggies (8-10 a
day)
�Limit alcohol 1-2 drinks a day
�Increase activity level
Please see standards for second half
BP Treatment in addition to Lifestyle
�First Line B/P Drugs
�If B/P ≥ 160 /100 start 2 drug combo� With albuminuria – start with either ACE or ARB
� No albuminuria - Any of the 4 classes of BP meds can
be used to tx hypertension
� ACE Inhibitors, ARBs, thiazide-like diuretics or calcium channel
blockers. (Avoid ACE and ARB at same time)
� Multiple Drug Therapy often required
�For best effect, administer at least one at bedtime
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Angiotensin Receptor Blockers
Beta Blockers
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Statin RecommendationsAge ASCVD or 10 yr risk >20% Recommended statin
<40 No None + lifestyle
<40 Yes High
If LDL >70, despite max statin dose
consider adding additional therapy
such as ezetimibe or PCSK9 Inhibitor
>40 No Moderate
>40 Yes If LDL >70, despite max statin dose
consider adding additional therapy
such as ezetimibe (Zetia) or PCSK9 Inhibitor
ASCVD Risk include: LDL >100, HTN, Smoke, Chronic Kidney Disease, albuminuria, family hx ACSVD. If pt can’t tolerate intended statin dose, use maximally tolerated dose.
AACE
Statin Therapy
�High intensity statins (lowers LDL 50%):
� atorvastatin (Lipitor) 40-80mg
� rosuvastatin (Crestor) 20-40mg
�Moderate intensity (lowers LDL 30-50%)
� atorvastatin (Lipitor) 10-20mg
� rosuvastatin (Crestor) 5-10mg
� simvastatin (Zocor) 20-40mg
� pravastatin (Pravachol) 40 – 80mg
� lovastatin (Mevacor) 40 mg
� fluvastatin (Lescol) XL 80mg
� pitavastatin (Livalo) 2-4mg
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Page 23© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
Coronary Vessel Disease�In those with known CVD, use:�Aspirin� Statin�B/P Med � In pts with prior MI, Beta Blockers should be continued
at least 2 years after the event
�Don’t use Actos or Avandia in pts with CHF�Diabetes Meds that significantly decrease CV
events:� SGLT-2i - Empagliflozin (Jardiance), canagliflozin (Invokana) and
dapagliflozin (Farxiga) – Eval GFR
� GLP-1 RA Semaglutide > liraglutide > dulaglitide > exenatide > lixisenatide
ABCs of Diabetes
�A1c less than 7% (avg 3 month BG)�Pre-meal BG 80-130�Post meal BG <180
�Blood Pressure < 140/90
�BP target <130/80�If 10 year CVD Risk > 15%
�Cholesterol � Statin therapy indicated?
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Page 24© Copyright 1999-2020, Diabetes Education Services www.DiabetesEd.net
A 78 yr old man, smokes ppd
�A1c was 8.1%, History of MI
�B/P 136/76 AM BG 100, 2 hr pp 190
�Chol – TG 54, HDL 46, LDL 98
�Meds:� Insulin – 16 units Lantus at HS
�Benazepril 20 mg
�Metoprolol 50mg
�Warfarin 5mg
�Actos 15 mg
Any meds missing?
Thank You
�Please email us with
any questions.
�www.diabetesed.net
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